MED SURG ATI PRACTICE -2010
TPN solution of 50 ml, no replacement bag. Next nursing action?
- Initiate 500 ml of 10% dextrose
2 hr post op traditional open approach cholecystectomy. Indicating need for
further nursing assessment?
- unilateral swelling of lower extremity
patient with tracheostomy requires suctioning. Appropriate nursing action?
- preoxygenate the client for 30 sec (with 100% oxygen for 30 seconds to 3
min) (only up to three passes, suction pressure 80-120, suction for 10-
15)
taking Viagra, discondtinue medication if he is also taking what other med?
- isosorbide mononitrate (imdur)
assessing client’s hydration status. Findings indicate fluid volume overload?
- distended neck veins
client diagnosed with DM. what indicates hypoglycemia?
- cool, clammy skin
client with small bowel obstruction and NG tube. Approptiate for nurse to
include in plan of care?
- assess for passage of flatus
suspected cholecystitis, expected finding?
- vague pain radiating to the right shoulder
client reports substernal precordial pain. Which sound should the nurse
document?
- pericardial friction rub
hypothyroidism, monitor which findings?
- constipation
client with osteomyelitis and is to receive dose of gentamicin. Which finding
indicates need to withhold medication?
- serum creatinine
heptic encephalopathy treated with lactulose. Adverse effect of medication?
- hypokalemia
type 1 DM who has acute bronchitis for past 3 days.
- take insulin even if youre unable to eat your regular diet
magnesium sulfate 1 g IV bolus. Adverse effect:
- respiratory paralysis
preoperative teacing for client with a right modified radical mastectomy.
Included in plan of care?
- presence of one or more surgical drains
client had TURP 12 hrs ago. Priority finding
- concentrated red urine with intermittent clots
client with rheumatoid arthritis, client reports increased joint pain. Which
lab finding anticipated?
- increased ESR
client with amyotpohic lateral sclerosis and admitted with pneumonia.
Priority assessment finding?
, - increased respiratory secretions
potassium sparing diuretic
- try to walk at least three times per week for exercise
administration of platelets
- last picture with 3 filters
client undergoing chronic renal dialysis. Client reports mscle cramps and
tingling senstaiton in hands. Which medication should nurse administer?
- calcitriol (rocatrol)
arteriovenous fistular for dialysis, which requires intervention by nurse?
- numb fingers distal to the fistula
warfarin (Coumadin) for chronic atrial fibrillation. Desired outcome?
- INR 2.5
Prednisone inhaler for client with asthma. Further instructions needed with>
- spaces two puffs 15 seconds apart
gastric lavage for client who has upper GI bleeding. Appropriate nursing
action?
- insert a large bore NG tube
open thoracotomy with chest tube insertion. What action should nurse take?
- keep chest tube collection chamber below the level of the lungs
hyperthyroidism
- BP 170/80
Oral iron supplement
- Eat more high fiber foods
Rheumatoid arthritis, nonpharmacologic interventions to reduce pain
- alternate application of heat and cold to affected joints
DKA condition improving?
- glucose 272 mg/dL
1 day post op following a thoracotomy, what indicated a tension
pneumothorax?
- chest asymmetry
TPB via PICC line. Finding to be reported
- magnesium 1.1
external fication devices for fracture of lower extremity
- use crutches with rubber tips
client with COPD reports shortness of breath, cough and fatigue. Client has
thick mucous. Appropriate nursing intervention?
- administer robitussin as prescribed
discharge teaching for above the knee amputation and temporary prosthesis.
Client needs further teaching with?
- soft mattress on my bed
albuterol via nebulizer for asthma exacerbation
- SaO2 increases to 95%
AIDS
- get an influenza vaccine every year
hormone replacement therapy adverse effects
- calf pain, numbness in arm, intense headache
TPN solution of 50 ml, no replacement bag. Next nursing action?
- Initiate 500 ml of 10% dextrose
2 hr post op traditional open approach cholecystectomy. Indicating need for
further nursing assessment?
- unilateral swelling of lower extremity
patient with tracheostomy requires suctioning. Appropriate nursing action?
- preoxygenate the client for 30 sec (with 100% oxygen for 30 seconds to 3
min) (only up to three passes, suction pressure 80-120, suction for 10-
15)
taking Viagra, discondtinue medication if he is also taking what other med?
- isosorbide mononitrate (imdur)
assessing client’s hydration status. Findings indicate fluid volume overload?
- distended neck veins
client diagnosed with DM. what indicates hypoglycemia?
- cool, clammy skin
client with small bowel obstruction and NG tube. Approptiate for nurse to
include in plan of care?
- assess for passage of flatus
suspected cholecystitis, expected finding?
- vague pain radiating to the right shoulder
client reports substernal precordial pain. Which sound should the nurse
document?
- pericardial friction rub
hypothyroidism, monitor which findings?
- constipation
client with osteomyelitis and is to receive dose of gentamicin. Which finding
indicates need to withhold medication?
- serum creatinine
heptic encephalopathy treated with lactulose. Adverse effect of medication?
- hypokalemia
type 1 DM who has acute bronchitis for past 3 days.
- take insulin even if youre unable to eat your regular diet
magnesium sulfate 1 g IV bolus. Adverse effect:
- respiratory paralysis
preoperative teacing for client with a right modified radical mastectomy.
Included in plan of care?
- presence of one or more surgical drains
client had TURP 12 hrs ago. Priority finding
- concentrated red urine with intermittent clots
client with rheumatoid arthritis, client reports increased joint pain. Which
lab finding anticipated?
- increased ESR
client with amyotpohic lateral sclerosis and admitted with pneumonia.
Priority assessment finding?
, - increased respiratory secretions
potassium sparing diuretic
- try to walk at least three times per week for exercise
administration of platelets
- last picture with 3 filters
client undergoing chronic renal dialysis. Client reports mscle cramps and
tingling senstaiton in hands. Which medication should nurse administer?
- calcitriol (rocatrol)
arteriovenous fistular for dialysis, which requires intervention by nurse?
- numb fingers distal to the fistula
warfarin (Coumadin) for chronic atrial fibrillation. Desired outcome?
- INR 2.5
Prednisone inhaler for client with asthma. Further instructions needed with>
- spaces two puffs 15 seconds apart
gastric lavage for client who has upper GI bleeding. Appropriate nursing
action?
- insert a large bore NG tube
open thoracotomy with chest tube insertion. What action should nurse take?
- keep chest tube collection chamber below the level of the lungs
hyperthyroidism
- BP 170/80
Oral iron supplement
- Eat more high fiber foods
Rheumatoid arthritis, nonpharmacologic interventions to reduce pain
- alternate application of heat and cold to affected joints
DKA condition improving?
- glucose 272 mg/dL
1 day post op following a thoracotomy, what indicated a tension
pneumothorax?
- chest asymmetry
TPB via PICC line. Finding to be reported
- magnesium 1.1
external fication devices for fracture of lower extremity
- use crutches with rubber tips
client with COPD reports shortness of breath, cough and fatigue. Client has
thick mucous. Appropriate nursing intervention?
- administer robitussin as prescribed
discharge teaching for above the knee amputation and temporary prosthesis.
Client needs further teaching with?
- soft mattress on my bed
albuterol via nebulizer for asthma exacerbation
- SaO2 increases to 95%
AIDS
- get an influenza vaccine every year
hormone replacement therapy adverse effects
- calf pain, numbness in arm, intense headache
